1. When do you tap a painful, swollen joint? When do you obtain imaging before arthrocentesis?
2. In a patient with monoarticular arthritis, do you send any serum labs such as WBC, ESR, or CRP? How do they guide your management?
3. Which synovial fluid studies do you send in order to help make the diagnosis? Which of these rule out septic arthritis?
4. Do you inject the joint with any medication for symptomatic relief? If so, which medication?
Is there any real evidence showing harm
Using a short course of NSAIDs
With a patient on Coumadin
Great question. Haven’t seen anything on this but we’ll do a lit search and get back to you.
There aren’t many great studies looking at clinical end points, although this case control study by Battistella, et al. would suggest that users of both are at double the risk of UGIB in an elderly population.
Arch Intern Med. 2005 Jan 24;165(2):189-92.
Risk of upper gastrointestinal hemorrhage in warfarin users treated with nonselective NSAIDs or COX-2 inhibitors.
Battistella M, et al.
This Korean study by Choi, et al., shows an INR increase >15% in near forty percent of the patients in a review of 98 patients on coumadin in an outpatient clinic:
J Korean Med Sci. Mar 2010; 25(3): 337–341.
Risk Factors of Drug Interaction between Warfarin and Nonsteroidal Anti-Inflammatory Drugs in Practical Setting
Kyung Hee Choi, et al.
To me, these would suggest approaching that combination with caution, especially in the elderly or those with any risk factors for or history of bleeding, particularly GI bleeding.
–Whitney for EM Lyceum